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<title>Incident Reporting Form</title>
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		<h1><a>Incident Reporting Form</a></h1>
		<form id="form_199158" class="appnitro"  method="post" action="">
					<div class="form_description">
			<h2>Incident Reporting Form</h2>
			<p>Fill this form to report an incident on H1N1 influenza </p>
		</div>						
			<ul >
			
					<li class="section_break">
			<h3>Patient Details</h3>
			<p></p>
		</li>		<li id="li_1" >
		<label class="description" for="element_1">Patient Name </label>
		<div>
			<input id="element_1" name="element_1" class="element text medium" type="text" maxlength="255" value=""/> 
		</div> 
		</li>		<li id="li_14" >
		<label class="description" for="element_14">Sex </label>
		<span>
			<input id="element_14_1" name="element_14" class="element radio" type="radio" value="1" />
<label class="choice" for="element_14_1">Male</label>
<input id="element_14_2" name="element_14" class="element radio" type="radio" value="2" />
<label class="choice" for="element_14_2">Female</label>

		</span> 
		</li>		<li id="li_2" >
		<label class="description" for="element_2">NIC/Passport </label>
		<div>
			<input id="element_2" name="element_2" class="element text medium" type="text" maxlength="255" value=""/> 
		</div> 
		</li>		<li id="li_6" >
		<label class="description" for="element_6">Patient's Private Address </label>
		<div>
			<textarea id="element_6" name="element_6" class="element textarea small"></textarea> 
		</div> 
		</li>		<li id="li_4" >
		<label class="description" for="element_4">Phone Number </label>
		<div>
			<input id="element_4" name="element_4" class="element text medium" type="text" maxlength="255" value=""/> 
		</div> 
		</li>		<li class="section_break">
			<h3>Incident Details</h3>
			<p></p>
		</li>		<li id="li_7" >
		<label class="description" for="element_7">Date </label>
		<span>
			<input id="element_7_1" name="element_7_1" class="element text" size="2" maxlength="2" value="" type="text"> /
			<label for="element_7_1">MM</label>
		</span>
		<span>
			<input id="element_7_2" name="element_7_2" class="element text" size="2" maxlength="2" value="" type="text"> /
			<label for="element_7_2">DD</label>
		</span>
		<span>
	 		<input id="element_7_3" name="element_7_3" class="element text" size="4" maxlength="4" value="" type="text">
			<label for="element_7_3">YYYY</label>
		</span>
	
		<span id="calendar_7">
			<img id="cal_img_7" class="datepicker" src="calendar.gif" alt="Pick a date.">	
		</span>
		<script type="text/javascript">
			Calendar.setup({
			inputField	 : "element_7_3",
			baseField    : "element_7",
			displayArea  : "calendar_7",
			button		 : "cal_img_7",
			ifFormat	 : "%B %e, %Y",
			onSelect	 : selectDate
			});
		</script>
		 
		</li>		<li id="li_11" >
		<label class="description" for="element_11">Observed time </label>
		<span>
			<input id="element_11_1" name="element_11_1" class="element text " size="2" type="text" maxlength="2" value=""/> : 
			<label>HH</label>
		</span>
		<span>
			<input id="element_11_2" name="element_11_2" class="element text " size="2" type="text" maxlength="2" value=""/> : 
			<label>MM</label>
		</span>
		<span>
			<input id="element_11_3" name="element_11_3" class="element text " size="2" type="text" maxlength="2" value=""/>
			<label>SS</label>
		</span>
		<span>
			<select class="element select" style="width:4em" id="element_11_4" name="element_11_4">
				<option value="AM" >AM</option>
				<option value="PM" >PM</option>
			</select>
			<label>AM/PM</label>
		</span> 
		</li>		<li id="li_13" >
		<label class="description" for="element_13">District </label>
		<div>
		<select class="element select medium" id="element_13" name="element_13"> 
			<option value="" selected="selected"></option>
<option value="1" >Colombo</option>
<option value="2" >Kaluthara</option>

		</select>
		</div> 
		</li>		<li id="li_3" >
		<label class="description" for="element_3">City </label>
		<div>
			<input id="element_3" name="element_3" class="element text medium" type="text" maxlength="255" value=""/> 
		</div> 
		</li>		<li id="li_8" >
		<label class="description" for="element_8">Description </label>
		<div>
			<textarea id="element_8" name="element_8" class="element textarea small"></textarea> 
		</div> 
		</li>		<li id="li_15" >
		<label class="description" for="element_15">Symptoms </label>
		<span>
			<input id="element_15_1" name="element_15_1" class="element checkbox" type="checkbox" value="1" />
<label class="choice" for="element_15_1">Fever</label>
<input id="element_15_2" name="element_15_2" class="element checkbox" type="checkbox" value="1" />
<label class="choice" for="element_15_2">Cough</label>
<input id="element_15_3" name="element_15_3" class="element checkbox" type="checkbox" value="1" />
<label class="choice" for="element_15_3">Sore Throat</label>
<input id="element_15_4" name="element_15_4" class="element checkbox" type="checkbox" value="1" />
<label class="choice" for="element_15_4">Difficulty in breathing</label>

		</span> 
		</li>		<li id="li_12" >
		<label class="description" for="element_12">Other Symptoms  </label>
		<div>
			<textarea id="element_12" name="element_12" class="element textarea small"></textarea> 
		</div> 
		</li>
			
					<li class="buttons">
			    <input type="hidden" name="form_id" value="199158" />
			    
				<input id="saveForm" class="button_text" type="submit" name="submit" value="Submit" />
		</li>
			</ul>
		</form>	
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